<span “=””>OBJECTIVE: United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) <span “=””>provides primary health care services including care for diabetes and hypertension, with limited resources under difficult circumstances in Gaza, West Bank, Jordan, Lebanon and Syria. A total of 114,911 people with diabetes were registered with UNRWA health centres in 2011. The aim of this cross<span “=””>-<span “=””>sectional observational study was to assess the quality of diabetes care in the UNRWA primary health care centres. METHOD: The study population consisted of 1600 people with diabetes attending the 32 largest UNRWA health centres and treated there for at least one year. Between April and Sept<span “=””>.<span “=””> 2012 data from medical records, including results of clinical examinations and laboratory tests performed <span “=””>during the <span “=””>last <span “=””>one <span “=””>year, current management including self-care education and evidence of diabetes complications were collected and recorded in a previously validated data collection form (DCF). Patients were interviewed and clinically examined on the day of the audit and blood collected for HbA1c testing which was done at a central lab using High-performance liquid chromatography (HPLC) method (HLC®-723G8 Tosoh Corporation, Japan<span “=””>)<span “=””>. Data was transferred from paper records into a computer and analysed with Epi-info 2000. RESULTS: Type 1 diabetes was present in 4.3% and type 2<span “=””> <span “=””>diabetes in 95.7%. Co-morbid hypertension was present in 68.5%; 90.3% were either obese (64.0%) or overweight (26.3%). Clinical management of diabetes was largely in line with UNRWA’s technical instructions (TI) for diabetes. Records for 2 hour postprandial glucose (2<span “=””> <span “=””>h PPG), serum cholesterol, serum creatinine, and urine protein analysis were available in 94.7%, 96.4%, 91.4% and 87.5%, cases, respectively. Records of annual fundoscopic eye examination were available in 47.3% cases but foot examinations were less well documented. Most patients (95.6%) were on anti-diabetic drugs—68.2% oral anti diabetic drugs (OAD) only, 14.4% combination of OAD and insulin, and 12.9% insulin only. While 44.8% patients had 2 h PPG ≤ 180 mg/dl, only 28.2% had HbA1c ≤ 7%; 55.5% and 28.2% had BP ≤<span “=””> <span “=””>140/90 and ≤130/80 mm of Hg respectively. Serum cholesterol ≥<span “=””> <span “=””>200 mg/dl, serum creatinine ≥<span “=””> <span “=””>1.2 mg/dl and macro albuminuria were noted in 39.8%<span “=””>,<span “=””> 6.4% and 10.3% cases respectively. Peripheral neuropathy (52.6%), foot infections (17%), diabetic retinopathy (11%) and myocardial infarction (9.6%) were the most common long term complications. One or more episodes of hypoglycaemia were reported by 25% cases in total and in 48% of those using insulin. 17.7% and 22.6% cases received no or ≥4 self-care education sessions respectively. CONCLUSION: The study confirmed that UNRWA doctors and nurses follow TI for diabetes and hypertension fairly well. Financial constraints and the consequent effects on UNRWA TI and policies related to diabetes care were important constraints. Key challenges identified<span “=””> <span “=””>were<span “=””>:<span “=””> reliance on 2 h PPG to measure control; non-availability of routine HbA1c testing, self-monitoring of blood glucose (SMBG) and statins within the UNRWA system; and high levels of obesity in the community. Addressing these will further strengthen UNRWA health system’s efforts of providing services for diabetes and hypertension at the primary care level. Given that most developing countries either have no or only rudimentary services for diabetes and hypertension at the primary care level, UNRWA<span “=””>’<span “=””>s efforts can serve as an inspiration to others.

Introduction: Preeclampsia is one of the most commonly encountered hypertensive disorders of pregnancy that accounts for 20% – 80% of maternal mortality in developing countries, including Ethiopia. For many years diet has been suggested to play a role in preeclampsia. However, the hypotheses have been diverse and often revealed inconsistent results across studies. Moreover, rarely were these hypotheses studied in Ethiopia. Therefore, this study aimed to explore whether the incidence of preeclampsia was related to nutrient or micronutrient deficiencies. Objectives: To describe the effect of nutrition and dietary habits on the incidence of preeclampsia. Methods: A facility based unmatched case-control study was conducted among 453 (151 cases and 302 controls) pregnant women attending antepartum or intrapartum care in public health facilities of Bahir Dar City Administration. Case-control incidence density sampling followed by interviewer administered face to face interview, measurement of mid-arm circumference (MUAC) and document review were conducted using a standardized and pretested questionnaire. Data entry and cleaning was done by Epi Info Version 3.5.3. The data were transported to SPSS Version 20 for analysis. Both bivariate and multivariate logistic regression analyses were applied. Backward stepwise unconditional logistic regression analysis was employed to determine the putative association of predictive variables with the outcome variable and to control for the effect of confounding variables. A P-value ≤ 0.05 was considered statistically significant at 95% confidence level throughout the study. Result: Those women having a MUAC value ≥ 25.6 cm were two times more likely than their counterparts to have preeclampsia (AOR = 2.49, 95% CI = 1.58, 3.94). Strikingly, higher odds of preeclampsia were found in women who reported to have taken coffee during pregnancy (AOR = 2.16, 95% CI = 1.32, 3.53). Similarly, those women who had anemia during the first trimester pregnancy were three times more likely than their counterparts to have incidence of preeclampsia (AOR = 2.80, 95% CI = 1.09, 7.21). The result in this study also revealed that taking fruit or vegetables during pregnancy was found to be protective of preeclampsia (AOR = 0.37, 95% CI = 0.19, 0.73, AOR = 0.45, 95% CI = 0.22, 0.91) respectively. In addition, folate intake during pregnancy has shown a significant independent effect on the prevention of preeclampsia in this study (AOR = 0.19, 95% CI = 0.10, 0.37). Conclusion and Recommendation: Vegetable and fruit consumption and folate intake during pregnancy are independent protective factors of preeclampsia. On the other hand, higher mid upper arm circumference, anemia and coffee intake during pregnancy are risk factors for the development of preeclampsia.

National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy (2000) Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. American Journal of Obstetrics and Gynecology, 183, S1-S22. http://dx.doi.org/10.1067/mob.2000.107928

Agrawal, S. and Walia, G.K. (2010) Prevalence and Risk Factors for Pre-Eclampsia in Indian Women: A National Cross Sectional Study. South Asia Network for Chronic Disease, Public Health Foundation of India, New Delhi.

Modder, J. and Fitzsimons, K. (2010) Management of Women with Obesity in Pregnancy. Centre for Maternal and Child Enquiries (CMACE) and the Royal College of Obstetricians and Gynaecologists (RCOG) Joint Guideline.

Background: Hypertensive patients with insulin resistance (IR) are at greater risk of cardiovascular disease and may represent a particular subset of hypertension (HTN) requiring special medical attention. Quantitative measurements of the IR are not suitable for routine clinical practice. Met-abolic syndrome (MetS) or simply abdominal obesity (AO) is surrogate of IR. The performance of the recently proposed Sub-Saharan Africa cut-off point of abdominal obesity for identifying IR in hypertensive patients has never been evaluated. Aims: The main objective was to compare the performance of the newly proposed Sub-Saharan Africa specific threshold of abdominal obesity (AO-SSA) to that of IDF (AO-IDF) in identifying IR in Congolese Black Hypertensive Patients. Methods: A cross-sectional study was conducted at the Heart of Africa Cardiovascular Center, Lomo Medical Clinic, Kinshasa Limete, DR Congo, between January 2007 and January 2010. Homeostatic model assessment (HOMA) index was calculated to determine IR. Multivariate logistic regression analysis was used to assess the independent determinants of IR. The intrinsic (sensitivity and specificity) and extrinsic (positive predictive value and negative predictive value) characteristics of the AO-SSA, AO-IDF, AO-ATP III, MetS-SSA, MetS-IDF, and MetS-ATP III were calculated. The kappa statistic was determined for agreement between the ATPIII, IDF and SSA defined AO and MetS with HOMA-IR. Results: Men represented the majority of the enrolled patients: 105 (64.4%) and the mean age of all participants were 57 ± 11 years. Insulin resistance was found in 79.1% of the study population with 88.7, 79.3, 84.6, 71.4, 75.5, 91.1, 60.3 and 44.8 respectively among patient with MetS-ATP, MetS-IDF, MetS-SSA, AO-ATP III, AO-IDF, AO-SSA, diabetics and non-obese non-diabetic hypertensive patients. In multivariate analysis, the risk of IR was associated independently and significantly (p < 0.05) with cigarette smoking, low-HDL-C, hyperuricemia, and diastolic HTN, as shown in the following equation: Y = ﹣1.404 + 1.054 Cigarette Smoking + 0.872 low HDL-C + 0.983 hyperuricemia + 0.852 diastolic hypertension. The AO-SSA, with 87.7% sensitivity and 67.6% specificity, was the only surrogate who showed an acceptable agreement with the HOMA-IR index. Abdominal obesity defined according to other thresholds and the metabolic syndrome whatever the used diagnostic criteria have a slight agreement with the HOMA-IR index. Conclusion: IR was found to be prevalent in our study population. Cigarette smoking, low-HDL-C, hyperuricemia, and isolated diastolic HTN magnify IR. The AO-SSA is an easy and cost efficient method to diagnose IR in Congolese Black Hypertensive Patients. Further study in wider group is indicated to validate our findings.

Mittal, B.V. and Singh, A.K. (2010) Hypertension in the Developing World: Challenges and Opportunities. American Journal of Kidney Diseases: The Official Journal of the National Kidney Foundation, 3, 590-598.

Longo-Mbenza, B., Ngoma, D.V., Nahimana, D., Mayuku, D.M., Fuele, S.M., Ekwanzala, F. and Beya, C. (2008) Screen Detection and the WHO Stepwise Approach to the Prevalence and Risk Factors of Arterial Hypertension in Kinshasa. European Journal of Cardiovascular Prevention and Rehabilitation: Official Journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology, 15, 503-508.http://dx.doi.org/10.1097/HJR.0b013e3282f21640

Members of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus (2003) Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care, 25, S5-S20.

Cleeman, J.I., et al. (2001) Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA: The Journal of the American Medical Association, 285, 2486-2497.

Salehidoost, R., Aminorroaya, A., Zare, M. and Amini, M. (2012) Is Uric Acid an Indicator of Metabolic Syndrome in the First-Degree Relatives of Patients with Type 2 Diabetes? Journal of Research in Medical Sciences: The Official Journal of Isfahan University of Medical Sciences, 17, 1005-1010.

Introduction: Blunt trauma to the penis is a rare but potentially serious injury that can occur by various mechanisms (e.g., kicks, accidents, sexual activity, and falls). The most common clinical presentation is sudden pain, swelling, and discoloration. Depending on the type and severity of injury, management can include conservative treatment or surgery, with the ultimate goal being the prevention of delayed complications. Case presentation: A 30-year-old male presented with penile pain, swelling, and redness as a result of blunt trauma to his penis 1 week after penile enhancement surgery using a subcutaneous soft silicone implant. Once the patient’s blood pressure was stabilized, surgical management consisted of exploration with evacuation of a large hematoma and removal of the subcutaneous penile implant to avoid further perioperative and postoperative bleeding. Discussion: Postoperative bleeding is a risk factor associated with almost all types of surgical procedures, and its prevention is best achieved by identification and elimination of potential causes pre- and postoperatively. Hypertension is another risk factor for excessive postsurgical bleeding, particularly bleeding associated with prosthetic implant surgeries, and should be considered for any potential surgical patient. Conclusion: With penile prosthesis and implant surgery, hypertension is an especially serious risk factor. Early surgical management is warranted in cases involving a major hematoma and swelling. Even cases with minimal bleeding should be evaluated in a timely manner, with surgical treatment indicated, rather than watchful waiting, to prevent further damage to the penis.

Hypertension defined as a systolic blood pressure of ≥140 and a diastolic blood pressure ≥90 is anextremely prevalent condition; and it is responsible for significant mortality and morbidity. NHANESdata from 2005-2006 found that nearly 30% of adult US population has HTN; and nearly 8% of the population has undiagnosed HTN. HBP mortality in 2008 was 61,005. Any mentioned mortality in 2008 was 347,689 (NHLBI tabulation of NCHS mortality data). More than 20% of patients with systemic hypertension have chronic renal insufficiency (NHANES). Hypertensive nephropathy is a leading cause of end-stage renal disease (ESRD) requiring dialysis or transplantation or leading to death. The incidence of hypertension is high but only a subset of hypertensive patients progress to frank renal failure. A subset of hypertensive patients develop proteinuria during the course of disease and manifest nephrotic syndrome. This syndrome includes marked proteinuria, edema, and low serum albumin. Neither the incidence nor the clinical significance of proteinuria in hypertension without diabetes is known. Progression to chronic renal failure in some patients is preceded by proteinuria as indicated on “dip-stick” analyses of random urine samples. It appears that proteinuria is likely to increase both prior to and during evident loss of glomerular filtration, but this clinical observation has never been formally confirmed. There is a need for large studies to answer these questions. We also need to focus on the roles that genetic and environmental factors play in development and progression of renal disease in the setting of hypertension and proteinuria.

US Renal Data System (2011) USRDS. Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. National Institutes of Health, National In-stitute of Diabetes and Digestive and Kidney Diseases, Bethesda.

Viazzi, F., Leoncini, G. and Pontremoli, R. (2013) Global Cardiovascular Risk Assessment in the Management of Primary Hypertension: The Role of the Kidney. International Journal of Hypertens, 2013, 542-646.

Introduction: Gender perspectives are gradually generating great interest in health matters. Hypertension is one illness where gender considerations are important. Advancements in knowledge of pathophysiology help in better understanding of diseases and improvements in treatment. Pre-menstrual syndrome has been reported to make hypertension less responsive to treatment. This work was therefore done to see if premenstrual syndrome contributed in some way to hypertension in women. Methodology: All female hypertensives consulting the author in a private specialized hypertension clinic were questioned using the University of Carlifornia at San Diego criteria with a view to determining if they suffered from pre-menstrual syndrome. The control status was also considered for each patient. Females who consulted over the same period and were not hypertensive served as controls. Result: Pre-menstrual syndrome was found to occur more in hypertensive women than normotensive controls; to a statistically significant extent (p < 0.05). Control tended to be poorer in hypertensives with pre-menstrual syndrome than those without. The difference however did not achieve statistical significance. Discussion: There is controversy surrounding the aetiology of pre-menstrual syndrome. However, each of the models albeit inconsistent is capable of initiating and sustaining hypertension. The result here shows that in women it is likely to be one of the many factors that could produce hypertension in those predisposed. Conclusion: Pre-menstrual syndrome should arouse suspicion of future hypertension, and should be sought in all female hypertensives. Its presence should evoke deliberate action to improve outcome or remove the need for pharmacotherapy, at least for some time.

Myocardial geometric remodeling is a response to increased stress which includes increased afterload situations during clinical conditions. In this review, we have focused on early and late geometric features in aortic stenosis, importance of recognition of these findings and consequences due to progression of valve disease. We have also pointed out the similarities in early focal and global myocardial geometric remodeling in acute and chronic conditions as hypertension and acute stress cardiomypathy which are associated with myocardial functional and geometric response to acute or chronic stress exposure and relevant increased afterload. In aortic stenosis, target organ involvement in disease progression has been evaluated and discussed in the report. In addition to quantitative evaluation of valve disease, importance of myocardial involvement and global assessment of patients with aortic stenosis also have been mentioned in the report. Finally, we have discussed the importance of global myocardial geometric changes and timing for surgery before development of heart failure in this specific group of patients.

Dweck, M.R., Boon, N.A. and Newby, D.E. (2012) Calcific Aortic Stenosis: A Disease of the Valve and the Myocardium. Journal of the American College of Cardiology, 60, 1854-1863.http://dx.doi.org/10.1016/j.jacc.2012.02.093

Garcia, M.J., Thomas, J.D. and Klein, A.L. (1998) New Doppler Echocardiographic Applications for the Study of Diastolic Function. Journal of the American College of Cardiology, 32, 865-875.http://dx.doi.org/10.1016/S0735-1097(98)00345-3

Yalcin, F., Yalcin, H. and Abraham, T. (2010) Stress-Induced Regional Features of Left Ventricle Is Related to Pathogenesis of Clinical Conditions with both Acute and Chronic Stress. International Journal of Cardiology, 145, 367-368.http://dx.doi.org/10.1016/j.ijcard.2010.02.041

Yalcin, F. and Müderrisoglu, H. (2009) Tako-Tsubo Cardiomyopathy May Be Associated with Cardiac Geometric Features as Observed in Hypetensive Heart Disease. International Journal of Cardiology, 135, 251-252.http://dx.doi.org/10.1016/j.ijcard.2008.03.018

Holmgren, S., Abrahamsson, T. and Almgren, O. (1985) Adrenergic Innervation of Coronary Arteries and Ventricular Myocardium in the Pig: Fluorescence Microscopic Appearance in the Normal State and after Ischemia. Basic Research in Cardiology, 80, 18-26.http://dx.doi.org/10.1007/BF01906740